Living with Stage 4 Chronic Kidney Disease

Conditions related to advanced CKD

In addition to heart disease and poor nutritional health, kidney disease can cause other health problems throughout your body including:

• Anemia (low red blood cell count)

• Mineral and bone problems

• High potassium (also called hyperkalemia)

If you have CKD stage 4, it is possible that you are probably experiencing some of these problems already. Your clinician will work with you to develop a treatment plan to help manage these problems and keep them from getting worse. Treatment may include diet, exercise, and medications. It is important that you follow your treatment plan to help keep you as healthy as possible. If you have CKD, you should ask you clinician about the risk and management of these conditions.

Managing anemia

Anemia happens when your red blood cells are in short supply. Red blood cells carry oxygen from your lungs to all parts of your body, giving you the energy you need for your daily activities. Anemia can cause you to look pale, feel tired or dizzy, have headaches, feel short of breath, and/or feel depressed or "down in the dumps." Speak to a clinician if you feel any of these symptoms and ask about getting checked for anemia.

Anemia reduces the flow of oxygen throughout your body, which forces your heart to work harder. Anemia has been linked with increased risk for heart disease. If you have anemia, one or more of the following may be suggested by a clinician:

• Eating more foods that have iron such as red meat, beans and green vegetables. However, eating foods that are rich in iron may be hard due to your kidney diet. A dietitian can help you plan meals that include iron and other minerals.

• Iron supplements by mouth in tablet or liquid form.

• A vitamin and mineral supplement with iron, vitamin B12, and folic acid. Your dietitian or clinician will help you choose one that is right for people with kidney disease.

• Iron medicine given by injection into a vein during visits to your healthcare provider's office or clinic.

Medicines called erythropoiesis stimulating agents (ESAs) might also be suggested. ESAs help your body make red blood cells. Your clinician would give the ESA to you as an injection under the skin.

Managing mineral and bone disease

Mineral and bone disease related to kidney disease happens when there is an imbalance in your blood levels of calcium and phosphorus. Bone and mineral disease can affect your bones, heart and blood vessels. When too much kidney function is lost, your kidneys can no longer filter out extra phosphorus and remove it from the body in the urine. Over time, phosphorus can build up to high levels in your blood. Other minerals can also become out of balance, including vitamin D, calcium and parathyroid hormone (PTH). This all can result in calcium leaving your bones they become weaker, more brittle, and are more likely to break. Some calcium may also end up in the heart and blood vessels, which can cause or worsen heart disease.

Signs and symptoms of mineral and bone disease might include itchy skin, bone pain, weak bones that break easily, blocked blood vessels, heart problems, anemia, nerve problems, difficulty fighting off germs.

Speak to a clinician if you have itchy skin or feel a deep pain in your bones and ask about getting checked for mineral and bone disease.

If you have If you have bone and mineral disease, one or more of the following may be suggested by a clinician:

• Lower phosphorus diet: Eating a lower phosphorus diet helps to keep your blood phosphorus under control.

• Phosphate binders: Phosphate binders are medicines that help to keep blood phosphorus levels under control.

• Vitamin D: Your body needs the active form of vitamin D. Your healthcare team will decide which type of vitamin D medicine is right for you

• Calcimimetics: Calcimimetics are medicines often used when blood PTH, calcium and phosphorus levels are too high.

• Calcium supplements: Speak to your clinician before taking a calcium supplement. The results of your blood tests will help show if you need to take extra calcium, or if your calcium level needs to be lower.

• Surgery: Some people with high PTH levels need surgery to remove some or all of the parathyroid gland if they do not respond to other treatments.

• Exercise: The exercises that may be most helpful are called strengthening and weight-bearing exercise. Check with your clinician before starting an exercise program.

Check out this infographic for more information about phosphorus and a kidney diet.

Managing high potassium (hyperkalemia)

Potassium is a mineral found in many of the foods you eat. It plays a role in keeping your heartbeat regular and your muscles working right. High potassium (also called hyperkalemia) is a medical problem in which you have too much potassium in your blood. When kidneys do not work as well as they should, the amount of potassium in the blood can increase. Too much potassium in your blood can be dangerous and can cause an irregular heartbeat or a heart attack.

At first, many people with high potassium have few or no symptoms. Early symptoms can include muscles that are weak numb or in pain, tingling, shortness of breath, nausea, or other unusual feelings.

Very high levels of potassium can lead to more serious symptoms and require immediate medical attention, and can include nausea or vomiting, shortness of breath, a heavier or irregular heartbeat, or chest pain. Very high potassium can still be dangerous, even if there are no symptoms.

Speak to a clinician if you feel any of these symptoms and ask about getting checked for high potassium.

A diet that is too high in potassium can raise potassium levels in your body. Many other things can also cause high potassium, including certain drugs and other diseases such as diabetes and heart disease. If you have If you have high potassium, one or more of the following may be suggested by a clinician:

• A low-potassium diet. A dietitian can help you create a meal plan that is low in potassium

• Possible changes in your medicines might be needed (determined by your clinician)

• Managing other conditions, such as high blood pressure, diabetes, and CKD

Certain medicines might also be used to help remove excess potassium from the body. These can include diuretics (water pills) or potassium binders. Your healthcare team will determine the right treatment and medication for you.

This infographic contains more information on the dangers of high potassium.

Managing fluid overload

Most people in the early stages of kidney disease do not need to limit the amount of fluids they drink. However, as kidney disease gets worse and reaches stage 4, your dietitian or clinician can let you know if you need to limit fluids and how much to drink each day.

Having too much water in your body is called fluid overload (or hypervolemia). One of the main functions of the kidneys is to balance fluid in the body. If too much fluid builds up in your body, it can have harmful effects on your health, such as difficulty breathing and swelling. Therefore, at some point, you may need to track your fluids to prevent fluid overload, especially if you receive dialysis.

Discuss with your clinician how much fluid you can have. Control thirst by avoiding salt and eating foods lower in sodium. Your dietitian can give you advice on how to control thirst and how to limit your fluid intake. Foods that melt at room temperature, such as ice cream and gelatin, are considered fluids. Patients on hemodialysis may need to limit their daily fluid intake to about 1 liter/day (about 32 ounces or 4 cups). Patients on peritoneal dialysis may also need to limit their fluid, but usually not as much as those on hemodialysis. But each person is different, so your clinician will tell you the amount that is right for you.

This app that can help you manage your fluid intake.

What can I do to manage CKD complications?

People with CKD stage 4 are at risk for conditions related to CKD, including anemia, mineral and bone problems, and high potassium. It is important to remember the following:

• Understand that people with CKD are at higher risk for conditions such as anemia, mineral and bone problems, and high potassium

• Be aware of the symptoms related to each disorder and report any new symptoms to your clinician

  • Anemia: Pale skin, pale, feeling tired or dizzy, headaches, shortness of breath, feel depressed or "down in the dumps"

  • Mineral and bone disorder: Itchy skin or feel a deep pain in your bones

  • High potassium: Muscle weakness or numbness, pain, tingling, shortness of breath, nausea, chest pain.

• If you have CKD, ask your clinician about these conditions and ask about being tested:

  • Anemia: Levels of iron and hemoglobin in the blood

  • Mineral and bone disorder: Levels of phosphorus, calcium, vitamin D and PTH in the blood

  • High Potassium: Amount of potassium in the blood

• Keep track of your kidney tests and any lab numbers related to these conditions. Speak to a clinician about access to your lab results. These resources can also help track lab results:

  • Flyer to help track your lab numbers

  • Spreadsheet to help keep track of lab results

• If you have any of these conditions, be sure to follow your treatment plan from your healthcare team. The treatment plan can include dietary recommendations or medications.